impact of transradial versus transfemoral approach for percutaneous coronary intervention on the outcome of patients presenting with acute coronary syndrome

Background: The transfemoral approach [TFA] has been until presently the main-stay for arterial access PCI in the setting of acute STEMI, while the transradial approach [TRA] is gaining ground in elective as well as primary procedures

Objectives: to assess the impact of transradial versus transfemoral approach for PCI on the outcome of patients presenting with acute coronary syndrome

Patients and Methods: prospective study was conducted on 100 patients presenting to Ain Shams University Hospitals Coronary Care Unit [CCU] with recent onset acute coronary syndrome [whether unstable angina [UA]/non-ST-segment-elevation MI [NSTEMI] or ST-segment-elevation MI [STEMI]] undergoing revascularization via percutaneous coronary intervention [PCI]. Patients were randomized into 2 equal groups, for the first group PCI was performed via TFA while for the second group via TRA

Results: Our study found that, with TRA we get less bleeding, less local vascular complications [8 [16%] vs 2 [4%], p=0.045] and less amount of dye used [169.60 +/- 21.28 versus 187.00 +/- 37.65 ml, p=0.006] without significant increase in fluoroscopy time [10.86 +/-4.88 versus 9.76 +/-4.74 mins, p=0.256] or radiation exposure. Although there was no significant difference in mortality and morbidity, TRA offers the patient a more simple procedure with less hospital stay [3.4 +/-0.948 versus 3.86 +/-0.808 days, p<0.01]

Conclusion: Radial artery access is a safe and effective approach for management of ACS. If performed by experienced operators, TRA should be the standard access in managing ACS specifically in STEMI

Mitochondrial alterations in children with chronic liver disease

Over recent years it has become apparent that the hepatocyte mitochondrion functions both as a cause and as a target of liver injury. Resultant dysfunction of mitochondria yields deficient oxidative phosphorylation, increased generation of reactive oxygen species, impairment of other metabolic pathways and activation of both necrotic and apoptotic pathways of cellular death. Methods: This study was conducted on 26 children and adolescents with chronic liver disease who presented to or were following up in the Pediatric Hepatology Clinic, Children's Hospital, Ain-Shams University. They were divided into three groups according to the aetiology of liver disease [GI= patients with Wilson's disease [WD], GII=patients with chronic hepatitis C, GIII=patients with chronic liver disease other than Wilson's and chronic hepatitis C].Ultrasound-guided gun liver biopsies were performed, under local anaesthesia for all the 26 patients, using a modified 18-gauge truecut needle. Two liver biopsy cores were taken from each patient. One for light and electron microscopic examinations and the other was immediately immersed in liquid nitrogen to be frozen and used for studying mitochondrial DNA deletions by PCR Liver steatosis was higher in the group of patients with Wilson's disease and other liver disease. Electron microscopic examination of the mitochondria revealed significant mitochondrial pleomorphism in patients with Wilson's disease and patients with chronic hepatitis C infection. Enlarged mitochondria were found to be more prevalent among patients with chronic hepatitis C infection. Three of our patients [11.53%] had mitochondrial DNA deletions. We developed scoring system for mitochondrial affection in our patients, 7 patients [32%] were considered to have mild mitochondrial affection, 9 patients [41%] had moderate mitochondrial affection, while 6 patients [27%] had severe mitochondrial affection. Four of the studied patients had no mitochondrial affection. Conclusion: Mitochondria affection is common in chronic liver disease. This mitochondrial affection might be responsible for some of the chronic liver disease manifestation such as easy fatiguability and steatosis

Non invasive detection of coronary artery stenosis using 64-slice computed tomography

Coronary artery disease [CAD] is the leading cause of death and disability in many countries. Conventional coronary angiography [CA] is currently the reference test for coronary artery lumen assessment, and its use has been steadily increasing over the last decade. Recent advances in multislice computed tomography [MSCT] seem to respond adequately to the need for a noninvasive and reliable assessment of the coronary artery lumen. This study was designed to determine the diagnostic accuracy of 64-Slice computed tomography [CT] in the detection of coronary artery stenosis using conventional coronary angiography as the reference standard. The study was done on 50 patients who were referred for MSCT [64 slice] computed tomography coronary angiography evaluation after being well prepared to obtain heart rate of less than 60 bpm, then they underwent invasive coronary angiography. In every patient the coronary artery tree was divided into 15 segments according to the American Heart Association 15 segments model of the coronary arteries and each coronary segment was compared between both examinations. The sensitivity, specificity and accuracy of MSCT to determine coronary stenosis were calculated. The sensitivity, specificity, positive and negative predictive values of 64 slice CT coronary angiography to detect significant coronary stenosis were 87.5%, 99.6%, 98.3% and 96.7% respectively. Regarding stenosis severity, the sensitivity of 64 slice CT coronary angiography to detect>90% stenosis and>60% stenosis were 95%and 56% respectively. MSCT 64 slice coronary angiography is a very valuable test for the diagnosis of coronary artery disease also due to its high negative predictive value it can be used to rule out significant coronary artery disease with very high accuracy

Study of the fate of detectable left atrial thrombi at repeated tranesophagealechocardiography in patients with mitral stenosis

Previous studies did not encourage balloon mitral valvuloplasty [BMV] when left atrial and /or LAA thrombi are present. Patients with LA and/or LAA thrombi are considered at high risk for thromboembolic events. So it is considered a major cause of morbidity and mortality in patients with mitral stnosis. To investigate the fate and stability of LA and/or LAA thrombi under the effect of oral anticoagulation this study included thirty patients with mitral stenosis having LA and/or LAA thrombi detected by TEE. They were subjected to full anticoagulation therapy controlled by INR of 2-3. Repeated TEE were done three and six months later. According to the results of this study the patients were grouped into two main groups: Group 1: included sixteen patients who had dissolved LA or LAA thrombi after anticoagulation therapy. It represented [53.33%] of all cases included in this study. In thirteen patients out of all the total sixteen patients representing group I, the thrombi were dissolved after three months therapy as they had clear LA and LAA in the second TEE study. They represented [81.25%] of group I and [43.33%] of all patients included in this study. In three patients the thrombi were dissolved after six month anticoagulation therapy, they represented [18.75%] of group I and [10%] of the whole patients included in this study. Group II: which included eleven patients [36.66%] all of them had non dissolved thrombi in LA and LAA in spite of six months anticoagulation therapy, three patients were excluded from the study. In conclusion: Complete resolution of LA and/or LAA thrombi occurs in a considerable number of patients [53.33%]. Age of the patients, size of the left atrium and size of LAA or LAA thrombi are considered the only significant factors influencing thrombus resolution. No other clinical or echocardiographic parameters could influence thrombus resolution. Majority of LA andyor LAA thrombi dissolve in the first three months with less incidence of resolution in the next months

IV Enoxaparin versus unfractionated heparin in elective percutaneous coronary intervention

The rapid progress in the field of interventional cardiology in the last few years necessitates a continuous search for the most safe and effective methods to gain an optimum results, either equipments or drugs. to examine the use of enoxaparin as an anticoagulant in elective PCI, and compare it with unfractionated heparin regarding the acute procedural complications and the immediate 24-hour post-PCI events. The study was conducted on 84 patients who were classified independently into 2 groups. 50 patients represent group [A], received IV single bolus of enoxaparin in a dose of 0.5mg/kg at the start of the procedure and 34 patients represent group [B], received the usual traditional dose of unfractionated heparin [10000-15000 units].All patients were prepared by clopidogrel or ticlopidin before PCI in addition to aspirin 150 mg daily.Follow up was done for all patients during the immediate 24 hours after PCI for death, myocardial infarction, myocardial ischemia requiring urget coronary intervention and cerobrovascular stroke. There was no statistical significant difference between the two groups regarding the type of vessels treated or number of stents placed. None of the patients of both groups experienced any of the following complications during the procedure or 24 hours after: major bleeding, myocardial infarction, myocardial ischemia requiring urgent surgical or repeat percutaneous coronary revascularization or death. The major difference between the two groups was the immediate sheath removal in the enoxaparin group, without sheath site complication [minor haematoma] which was observed in 9% of the UFH group. Angiographic complications were coronary artery dissection [in one patient in group A [2%] and 3 patients in group B [9%]] and acute closure of the culprit vessel [occurred in one patient in group A [2%] and none in group B. The results were quite encouraging, with no statistical differences between the two arms of the study regarding the acute complications and the clinical outcome. The use of enoxaparin in this reduced dose is feasible in elective PCI with adequate level of anticoagulation without need for monitoring its anticoagulant effect. The early sheath removal in group A necessitates further studies to assess its impact on the duration of hospital stay and the possibility of early discharge of the patients

Relation of papillary muscle traction to autonomic nervous system dysfunction as evaluated by head-up-tilt-test in mitral valve prolapse

Mitral valve prolapse [MVP] is one of the commonest valvular abnormalities and is characterized by systolic superior leaflet displacement. This results in abnormal tension on the papillary muscles which may lead to, or is associated with alteration in the autonomic functions. The aim of this work is to detect and assess papillary muscle traction [PMT] in patients with idiopathic MVP in a trial to correlate it with any autonomic dysfunction as evaluated by head-up-tilt test [HUTT]. Thirty symptomatic MVP patients and a control group of 15 persons [cardiologically free], aged 15-35 years, were enrolled in the study. They were all thoroughly evaluated clinically, radiologically, electrocardiographically and by ECHO-Doppler. Patients with secondary causes for MVP were excluded. PMT was measured by 2-dimentional ECHO in all patients and controls who were subsequently subjected to HUTT. The obtained results showed both groups to be comparable. The MVP patients showed mitral regurgitation [MR] in 13 cases [43.3%]. Seventeen patients [56.7%] had MVP with no MR. PMT was greater in patients than in controls [5.7+/-3 versus 0.85+/-0.7mm], p value <0.001. Leaflet displacement as well as PMT index were also significantly higher in patients than in controls [p<0.001]. HUTT was positive [provoking syncope or presyncope associated with hypotension, bradycardia, or both] in six MVP patients [20%] and in none of the controls. HUTT appeared to be predictable by four of the studied parameters, namely, leaflet displacement, PMT, traction index and MR. Ten patients had PMT >/=6mm and 20 patients had it <6mm as shown by ECHO. Six out of the 10 patients who had PMT of >/=6mm had abnormal response to HUTT, while none of the 20 patients with PMT <6mm, and none of the controls had an abnormal response to HUTT. A statistically derived predictor value of >/=6mm PMT should be considered as an indicator to perform HUTT to MVP patients in a trial to detect asymptomatic patients prone to syncope. We recommend that PMT be a part of routine ECHO examination of MVP patients. Those with MR or PMT of 6 mm or more should be evaluated by HUTT for the occurrence of syncope or other manifestations of autonomic dysfunction aiming at avoidance or decrease of morbidity in this group of patients

Percutaneous inferior vena cava filters 3 years experience

This is a retrospective study of 22 patients in whom a Titanium Greenfield Vena Cava filter was placed, between 1992 and 1994. Indications for placement were mainly for patients with deep venous thrombosis or pulmonary embolism with either anticoagulant failure or contraindication. Several technical difficulties and complications are described along with the suggestion about how best to avoid them. A comparison between this type of filter and the stainless steel model is described and showed the superiority of the titanium model. Mortality rate was 4.5% [1 case], and on long term follow up 1 case had recurrence of pulmonary embolism and no cases showed signs of venous stasis or vena cava occlusion. It was concluded that, the use of the titanium filter compares favorably with reports in the literature and is improving as experience is gained. Careful estimation of the cost benefits of using this device is needed as indication for it's use and confidence of the physician increases

Fungal infection in urinary bilharziasis

This study was carried out on 50 patients [40 males, and 10 females] suffering from urinary schistosomiasis with bladder complications. Urine of each patient was collected aseptically, examined microscopically, cultured on nutrient agar, blood agar, MacConkey[s] agar and Sabouraud[s] dextrose agar. Fungal and bacterial growth were identified. Out of the 50 patients, 2 [one male and one female] had Candida albicans with the percentage of 4 percent, and 39 had bacterial infections with the percentage of 58 percent. The bacteria isolated from the 29 patients, in their order of frequency were E. coli, isolated from 16 patients with the percentage of 51.6 percent, Klebsiella isolated from 6 patients with the percentage of 19.4 percent, Proteus species isolated from 5 patients with the percentage of 16 percent. Staphylococcus aureus isolated from 1 patient with the percentage of 3.2 percent and finally one mixed infection [E. coli and Pseudomonas] was isolated with the percentage of 3.2 percent

Aerobic and anaerobic bacterial causes of acute meningitis

In this work a trial was done to study the aerobic and anaerobic bacteria causing acute meningitis among Egyptians. Cerebrospinal fluid samples were obtained from 55 cases of acute meningitis attending Imbaba and Abbasia fever hospitals during the period from Nov. 1987 to Jan. 1988. Each CSF sample was examined microscopically and cultured aerobically in 5% CO2 and anaerobically. Out of 55 cases 32 cases [58.2%] were positive for aerobic bacteria. The aerobic bacteria were N. meningitides from 17 cases [30.9%] H. influenzae from 5 cases [9.1%], S. penumoniae from 5 cases [8.3%], E. coli from 4 caes [8.3%] and S. aureus from 2 cases [93.6%]. The anaerobic organism was gram-negative diplococcus belonging to the family veillonellaceae